Capturing Value in Advanced Medical Imaging

On December 12, a bipartisan bill entitled the Excellence in Diagnostic Imaging Utilization Act of 2013 (HR 3705) was introduced in the House of Representatives which would require clinicians to use electronic clinical decision support tools (CDS) before ordering advanced diagnostic imaging tests for Medicare patients.  Structured around appropriate use criteria  developed by professional medical societies, the tools would aim to increase the value of advanced imaging studies by informing and guiding practitioners’ decisions across a variety of clinical settings.

Such tools would provide active feedback on the appropriateness and evidence base of various imaging modalities, and would require physicians to furnish rationales for ordering tests that are inconsistent with appropriate use criteria.  The bill also envisions the creation of registries that document how diagnostic tests are used in order to facilitate research and to enable feedback to clinicians on metrics related to appropriate use criteria.  In a press release, the American College of Radiology lauded the proposed legislation, stating that it would “revolutionize the specialty of radiology.”

Mandating the use of electronic clinical decision support tools portends at least three key improvements in clinical workflows and healthcare quality more broadly.

First, incorporating CDS into advanced imaging orders can serve to limit utilization of unnecessary tests and maximize the usefulness of tests conducted.  In support of this aim, one major retrospective cohort study found that implementation of targeted CDS was associated with significant reductions in use of frequently unnecessary tests, such as lumbar MRI for nonspecific low back pain or sinus CT for sinusitis without suspected complications.  Another meta-analysis found strong evidence in favor of the capacity of clinical decision support systems to improve a variety of healthcare process measures.  By helping to reduce unnecessary tests, CDS can thus enhance patient safety by minimizing unnecessary iatrogenic radiation exposure, while improving the overall value of tests ordered.

Second, requiring referring physicians to use CDS can augment radiologists’ efficacy. Given increasing workload trends for radiology specialists, requiring clinicians to consult appropriate use criteria via decision support tools prior to issuing radiology referrals can help to optimize the productivity of radiologists by ensuring that the test they perform and interpret are sufficiently indicated.

Third, effective use of CDS together with the registries envisioned by the recent bill can provide a robust platform for data mining and applied informatics that can propel medical research, enable evidence-based innovations and catalyze advances in quality improvement.

To realize these benefits, careful planning around implementation of CDS will be essential.  In particular, ensuring that CDS systems and registries are interoperable, effectively configured, and compatible with pre-existing electronic medical record systems will be pivotal to mitigate unintended consequences and to ensure efficient use patterns.

Whatever the outcome of the proposed legislation, the ideas and ideals it encapsulates represent a novel approach to healthcare delivery that can be replicated in a diverse array of medical settings as practitioners and policy makers look for ways to promote high-value care in today’s evolving medical ecosystem.

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